Complaint Investigation Report

The allegation of “Staff did not respond to residents’ requests for assistance in a timely manner.” alleges that facility residents who press their call button have to wait an unacceptable amount of time for facility staff to respond to their requests for assistance. Throughout the investigation of this complaint LPAs Byrne and Cortez interviewed twelve (12) randomly selected residents of the facility. Eleven (11) residents interviewed did not express concerns with the amount of time it takes facility staff to respond to resident’s requests. Residents reported that staff have responded to a pendant press within as little as five (5) minutes but often within 10-15 minutes. LPA Byrne conducted unannounced tests of the signal alert system in four (4) resident units across multiple days of inspection. LPA received responses from the pendant presses that ranged from no less than four (4) minutes to no more than twenty-two (22) minutes. LPA interviewed ED-I who stated that the facility aims for a response time of no more than twenty (20) minutes. LPA observed the facility’s call button response logs from January 2026 - February 2026 and observed an average response time of approximately five (5) minutes. Of two hundred and fifty six (256) call responses in January and two hundred forty seven (247) call responses in February only sixteen (16) exceeded the facility's expected response time of twenty (20) minutes (Excluding outliers where the system was turned into the front desk for battery replacement and the call was not cleared on the system). Of those sixteen (16) only nine (9) response times exceeded twenty five (25) minutes. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not respond to residents’ requests for assistance in a timely manner.” Therefore, the allegation is deemed Unsubstantiated at this time.

The allegation of “Staff did not provide residents with adequate food service.” alleges that the food served to residents is not good quality and the facility runs out of some meals to provide residents. LPA Byrne conducted a physical plant tour of the facility and observed the facility to have a sufficient supply of two (2) days perishable and seven (7) days non-perishable foods. LPA interviewed facility staff including the Director of Dining, a Sous Chef, and a Server. Staff interviewed stated that the facility offers an “Everyday menu” and a “Specials menu” for each meal service. Staff explained that the facility stocks approximately 200 portions of the items listed on the specials menu for each dining service as not every resident orders meals off of the specials menu. Staff stated that specials are changed daily and are offered on a first come first serve basis. Staff stated that once they run out of portions no additional special items are offered for the meal service. Staff reported that items on the everyday menu are always available for residents to order if the special items run out. Interviews with staff and residents revealed that there have been times where the food that is ordered takes longer than normal to be served to the residents and due to this delay residents were served cold meals. CONTINUED ON LIC 9099C.